* There are no deductibles and no yearly limits on services, and there are no claim forms to fill out. Your savings are in place when you visit a network dentist. You just show up for your dental appointment and make your payment – what could be easier? The dentists must meet the Plan’s standard of quality and service. All have agreed to provide dental care at an affordable price to its members. Since there is no waiting period for your dental services to begin, pre-existing dental conditions are covered and best of all, the dental plan services starts on the first day of next month if the application is received by the dental plan on or before the 20th of this month. Review the sample schedule below and see how easy it is for you or your entire family to enjoy these quality dental services.

The fees shown are a sample of some frequently used dental procedures. When you enroll for the plan, you will pay reduced fees called copayments. These reduced fees are only available from providers who participate in our network. After you enroll, a complete list of copayments will be mailed to your home along with your Individual Dental Service Agreement. The sample demonstrates potential savings with the Secure Choice plan and may not reflect your actual results.

SECTION I: PLAN DENTIST SERVICES: (Subject to Exclusions and Limitations Listed in Agreement)

Plan Benefits are provided for the dental services listed in this Plan Dentist Services Section of the Copayment Schedule only when services are provided by Member’s selected Plan Dentist. Limited benefits for Emergency Services from other Plan Dentists are provided as specifically stated in the EMERGENCY SERVICES Article of Agreement. Plan Benefits are not available for dental services that do not appear on the Copayment Schedule.

Member is responsible for paying the amount listed in the Member Copayment column, plus any additional laboratory (“lab”) fees for certain dental services. Payment may be due at the time the service is received or in accordance with Plan Dentist’s billing procedures. Lab fees may apply to asterisked (*) services. For such a service, the lab fee is that Plan Dentist’s normal retail lab fee for that service.

The most current dental terminology may not be reflected in the Copayment Schedule. However, Plan Benefits will be based on the most current dental terminology. Company reserves the right to update the Copayment Schedule to reflect the most current dental terminology, with at least thirty (30) days written notice to Subscriber.

The Plan Dentist selected by Member may not perform all listed services. To fully understand payment responsibility for dental services, Member should discuss availability of services, the proposed treatment, and cost with selected Plan Dentist prior to treatment. Availability of any specific general dentist as a Plan Dentist is not guaranteed.

Payment for all services received from a Non-Plan Dentist (at the Non-Plan Dentist’s entire normal retail charge) is the responsibility of Member, except for limited benefits for Emergency Services as specifically stated in the EMERGENCY SERVICES Article of Agreement.